Summary On 29 October 2004, at 0653 Pacific daylight time (before daylight), a Britten Norman BN2P Islander (Navair612) was holding in position at the threshold of Runway08R awaiting take-off clearance. While Navair612 was holding, a deHavilland DHC-8 (Jazz8191) was instructed to taxi to position on Runway08R behind the Islander. When issuing this instruction, the controller thought that Jazz8191 was on TaxiwayL at the threshold of Runway08R, when Jazz8191 was actually on TaxiwayL2, farther down the runway, ahead of Navair612. The controller then cleared Navair612 for take-off on Runway08R as Jazz8191 was taxiing to position on that runway from TaxiwayL2. A high-speed collision nearly occurred when Navair612, during rotation for lift-off, passed by Jazz8191. Ce rapport est galement disponible en franais. Other Factual Information The weather at Vancouver International Airport at 0600 Pacific daylight time1 was as follows: wind 110True (T) at 10knots, clouds scattered at 800feet above ground level (agl), broken at 2500feet agl, broken at 5000feet agl, visibility 3statute miles, temperature 7C, dew point 6C, altimeter setting 30.14inches of mercury. The relevant air traffic control (ATC) positions were: clearance delivery, south ground and south tower. On the morning of the occurrence, the clearance delivery and south ground control positions were staffed by one controller. When the south ground controller was issuing taxi instructions to Jazz8191, the crew was asked if they would like to use TaxiwayL2 or the end of the runway; the crew responded Lima2. They taxied to L2 and held short of Runway08R awaiting further instructions or take-off clearance. At the time of the occurrence, two arriving aircraft were on final for Runway08R, and seven aircraft were waiting to depart on Runway08R (see AppendixA - Aircraft Positions). Aircraft departing on Runway08R can approach the threshold from either TaxiwayA on the south side of the runway, or TaxiwayL on the north side. Jazz8191, one of the waiting aircraft, was on TaxiwayL2, on the north side farther down the runway. Of the other six aircraft, four were on TaxiwayL (a DHC-8, two Islanders, another DHC-8) and two were across the runway on Taxiway A (the Islander [Navair612] and a Mitsubishi MU-2). After the first DHC-8 on TaxiwayL departed, the first arriving aircraft landed. The south tower controller then cleared Navair612 to position (from TaxiwayA at the threshold) and requested that the pilot move ahead to permit a DHC-8 to line up behind. Jazz8191 was then cleared to position behind the Islander. The crew of Jazz8191 did not see the Islander ahead of them and could not see the threshold because of the angle of the taxiway they were on. The south tower controller did not state the runway entry position because he thought that Jazz8191 was at the runway threshold. Controllers are required to issue the name of the runway intersection or taxiway with the authorization only if the position being taxied to is not at the threshold of the departure runway. Pilots are not required to state or to read back the runway entry location. The controller had arrived for his fifth day shift at approximately 0620. He conducted a self-review of the daily unit log, operations directives and NOTAMs (Notices to Airmen). Some taxiway closures were in effect on the airfield, but none affected aircraft taxiing for departure on Runway08R. The controller had worked two night shifts some two weeks before the occurrence, and at that time, TaxiwayL2 had been closed. The south tower controller being relieved conducted a hand-over briefing, and the change of control of the south tower position occurred at0630. The airport is served by airport surface detection equipment (ASDE), a short-range radar system that detects primary targets on the airfield, and airborne targets below 200feet and within one nautical mile of the airport. The system displays secondary surveillance targets and associated data tags for aircraft using a transponder, if the appropriate information is entered into the computer system, normally through a flight plan. Because departing flights normally do not switch their transponders on until cleared for take-off, they appear only as unidentified primary targets. The ASDE system at Vancouver International Airport is known to randomly display erroneous information. It is common for false targets to appear and for real targets to disappear. Data tags assigned to provide identification can disappear or swap between two targets that pass in close proximity. Occasionally, signage or barricades on the airfields show up as targets. Because of these unresolved problems, the ASDE system at Vancouver International Airport is not used as a sole reference tool, but only as an aid. In this occurrence, the controller did not rely on the ASDE and did not refer to it consistently. At the time of the occurrence, a target was displayed on TaxiwayL2. However, because of the known ASDE problems, the south tower controller did not think that the target was an aircraft. The controller did not verify the target with the available binoculars, radio communications, or the south ground controller at the adjacent workstation. When Jazz8191 was cleared to position behind the Islander (which was at the threshold), the controller did not note that the target was moving onto the runway at TaxiwayL2. To aid in indicating closures on the airfield, controllers commonly electronically insert solid-coloured blocks on the ASDE monitor to obscure closed portions of the field. No closures were indicated in this manner for the taxiways involved in this occurrence. During the pre-shift self-review and subsequent transfer of position responsibility briefing by the controller being relieved, no information was presented to the incoming south tower controller to indicate that TaxiwayL2 was closed. Diminished capability of the human eye at night adversely affects the ability of pilots and controllers to see unlit objects, to identify the location and the motion of objects on the ground or in the air, to judge distances between objects, and, therefore, to maintain good situational awareness based on visual inputs alone.2 The sole pilot of Navair612 did not see the DHC-8 entering the runway at TaxiwayL2 until he was passing by it when rotating for lift-off. The threshold of Runway 08R is more than one nautical mile from the control tower, further increasing the difficulty for a controller to identify individual aircraft at the threshold. Aircraft departing Vancouver International Airport make their first contact with ATC on the clearance delivery frequency. There was a concern that forecast weather conditions may restrict the departures of some aircraft, so each flight was requested to provide its authorized departure weather minima. That information was recorded by hand on each flight progress strip. On the flight progress strip for Jazz 8191, the handwritten entry for departure weather encroached on the box designated for the taxi route instructions. Subsequently, Jazz8191 contacted south ground control for taxiing instructions and was assigned TaxiwayL2. The taxiway designator L2 was written in the appropriate box; however, it was displaced and the digit 2 was partially obscured. The south tower controller retrieved that flight progress strip from the board between the clearance delivery/south ground position and the south tower position and placed it in sequence in a top-to-bottom order at the work position of the south tower controller. The controller's scan of the flight progress strips for the four remaining departures from the north side of the runway did not detect that Jazz8191 was assigned TaxiwayL2, whereas the rest were assigned TaxiwayL. During hours of darkness, interior lighting levels in the tower are subdued to allow for visual observation of the airfield. A brief random survey of controllers indicated that they found the lighting levels to be adequate to read the flight progress strips effectively. When Jazz 8191 was instructed to taxi to position behind the Islander (Navair612), the Jazz flight crew apparently acknowledged the instruction; however, their acknowledgement was blocked by another transmission from an unidentified source. The acknowledgement did not appear to challenge the south tower controller's instruction regarding the missing taxiway location required for an intersection departure. The south tower controller queried as to who had made the last call, and a transmission came from an unidentified source indicating that they were the DHC-8 behind the Islander, followed by some comments about the Islander's navigation lights not being illuminated. Several transmissions followed from unidentified sources regarding navigation lights on Islanders. Although proper radio telephony procedures are well documented, the use of non-standard radio procedures prevailed among the group of pilots participating in the navigation light discussion. During this time, the south tower controller cleared Navair612 for take-off from Runway08R. At the time that Navair612 was starting its take-off roll, Jazz8191 was moving toward the runway on TaxiwayL2. The pilots of Jazz8191 were looking farther down the runway, toward the mid-field area, for the Islander that they were instructed to follow. TaxiwayL2 is a high-speed exit for the reciprocal Runway26L, and this angle makes it difficult for a crew to view Runway08R (over their right shoulder) toward the threshold. As the aircraft was proceeding onto the runway, the crew became uneasy and decided to turn to their right to view the runway toward the threshold. At that time, they saw the landing lights of Navair612 coming down the runway on the take-off run. The crew stopped the aircraft and switched on all exterior lights as Navair612 rotated for lift-off in front of them. It is likely that, before the take-off clearance for Navair612, all six remaining departures were able to monitor the south tower control frequency. Most, if not all, of the flight crews waiting to depart operate out of Vancouver International Airport regularly and would have been familiar with other local operators and aircraft types. No one drew attention to the fact that, when Jazz8191 was instructed to take position behind Navair612, no Jazz aircraft was in a position to comply with that instruction. On 25 October 2000, a runway incursion event with many similarities occurred at night at Vancouver International Airport on Runway26L (the reciprocal of Runway08R). The TSB investigation (report A00P0206) found that, of two aircraft on the runway, both accepted and simultaneously read back a take-off clearance that had been directed to one, and that the clearance had not included the taxiway intersection. As a result of that occurrence and of previous occurrences, NAV CANADA adopted a procedure that has become a requirement in the Air Traffic Control Manual of Operations (ATC MANOPS); for take-offs other than from the threshold, controllers are to include the taxiway or runway intersection with the take-off clearance. This information is also reflected in Section RAC4.2.5 of the Aeronautical Information Manual (AIM). The National Civil Aviation Safety Committee formed a Sub-Committee on Runway Incursions (SCRI) in response to an increase in occurrences of this nature. The SCRI completed two studies and made several recommendations to minimize the risk of runway incursions. The issue of intersection departures was identified in Recommendation 4.7 of the SCRI, published in September2000, which recommended that Transport Canada and NAV CANADA collaborate to develop a policy regarding intersection departures. Although discussions were held, no policies regarding intersection departures were developed. Consequently, flight crews are currently not required to include the taxiway or runway intersection with clearance onto a runway. The SCRI agreed to a recommendation to amend the training standards in the Commercial Air Service Standards (CASS) to include a regulatory requirement for communication training. Notices of Proposed Amendment (NPAs) to the standards were proposed, and agreed to, at the June2003 Commercial Air Service Operations (CASO) Technical Committee meeting, but are awaiting legal editing and promulgation. The proposals included additional emphasis on International Civil Aviation Organization (ICAO) standard phraseology, and on the need to minimize unnecessary cockpit tasks under the communication and taxiing paragraphs respectively.